How To Use CPT Code 72157

CPT 72157 describes the diagnostic procedure of magnetic resonance imaging (MRI) of the thoracic spinal canal and contents. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 72157?

CPT 72157 is used to describe the diagnostic procedure of MRI of the thoracic spinal canal and its contents. This code is specifically for imaging performed without the use of contrast material initially, followed by the administration of contrast material and further sequences to enhance the quality of the images.

2. Official Description

The official description of CPT code 72157 is: ‘Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic.’

3. Procedure

1. The provider begins by positioning the patient on the scanning table, which slides into a large tunnel-shaped magnetic scanner.
2. The patient is instructed to hold their breath and remain still while the images of the thoracic spine are captured.
3. The MRI machine generates radiofrequency signals from the body, which are used to create a series of images that display slices of the thoracic spine.
4. Initially, the images are taken without the administration of contrast material.
5. After the initial images are obtained, contrast material is injected into the patient to enhance the visibility of internal structures or organs.
6. Additional sequences may be performed to further improve the quality of the images.
7. The provider reviews the images, analyzes the findings, and prepares a written report.

4. Qualifying circumstances

CPT 72157 is used for patients who require diagnostic imaging of the thoracic spinal canal and its contents. This procedure is typically performed to diagnose, manage, and treat diseases or conditions affecting the thoracic spine. The use of contrast material is necessary to improve the visibility of internal structures or organs. Providers who perform this procedure must have the necessary expertise and equipment to conduct MRI scans.

5. When to use CPT code 72157

CPT code 72157 should be used when a provider performs an MRI of the thoracic spinal canal and its contents without contrast material initially, followed by the administration of contrast material and further sequences. This code is appropriate for diagnostic purposes and should be used when the specific criteria are met.

6. Documentation requirements

To support a claim for CPT 72157, the provider must document the following information:

• Indication for the MRI of the thoracic spinal canal and contents
• Whether contrast material was used and the specific type of contrast material administered
• Date and time of the procedure
• Any additional sequences performed
• Findings and interpretation of the images
• Preparation of a written report by the provider

7. Billing guidelines

When billing for CPT 72157, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately report whether contrast material was used and the specific type of contrast material administered. Additionally, follow the appropriate guidelines for reporting the professional and technical components of the service, using the appropriate modifiers if necessary.

8. Historical information

CPT 72157 was added to the Current Procedural Terminology system on January 1, 1992. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with suspected spinal cord compression undergoes an MRI of the thoracic spinal canal and contents without contrast material initially, followed by the administration of contrast material and further sequences to assess the extent of the compression.
2. An individual with a history of trauma to the thoracic spine undergoes an MRI to evaluate for any spinal cord or nerve root injuries. The procedure is performed without contrast material initially, followed by the administration of contrast material and further sequences.
3. A patient with persistent back pain and suspected spinal stenosis undergoes an MRI of the thoracic spine without contrast material initially, followed by the administration of contrast material and further sequences to assess the presence and severity of the stenosis.
4. An individual with a known spinal tumor undergoes an MRI of the thoracic spinal canal and contents without contrast material initially, followed by the administration of contrast material and further sequences to evaluate the tumor’s size, location, and involvement of surrounding structures.
5. A patient with a history of infection in the thoracic spine undergoes an MRI without contrast material initially, followed by the administration of contrast material and further sequences to assess the extent and resolution of the infection.